Depressive Disorders: DSM-5 Criteria and Key Features

Major Depressive Disorder (MDD) - Core Rule

At least 5 symptoms during the same 2-week period, representing a change from previous functioning. At least one must be depressed mood or loss of interest/pleasure (anhedonia). Symptoms must cause clinically significant distress/impairment and not be better explained by substances, medical conditions, or psychotic disorders.

MDD - SIGECAPS

Sleep disturbance; Interest decreased/anhedonia; Guilt/worthlessness; Energy decreased; Concentration/indecisiveness; Appetite/weight change; Psychomotor agitation/retardation; Suicidal ideation/death thoughts. Add depressed mood to reach the DSM symptom list.

MDD - Suicidality

Recurrent thoughts of death, suicidal ideation, a suicide attempt, or a specific suicide plan can count as one MDD symptom. On an exam, safety assessment comes first when suicidal intent, plan, means, or imminent danger is suggested.

MDD - Children & Adolescents

Depressed mood may present as irritable mood. Weight criterion may appear as failure to make expected weight gains rather than weight loss.

MDD - Bereavement

Bereavement does not automatically exclude MDD. Determine whether the full depressive syndrome, severity, impairment, and clinical context support MDD.

Persistent Depressive Disorder (Dysthymia)

Depressed mood for most of the day, more days than not, for at least 2 years in adults or 1 year in children/adolescents. In youth, mood may be irritable.

PDD - Additional Symptoms

While depressed, at least 2: poor appetite/overeating, insomnia/hypersomnia, low energy/fatigue, low self-esteem, poor concentration/difficulty making decisions, or hopelessness.

PDD - Symptom-Free Period

During the 2-year adult period (1 year for youth), the person has not been without the relevant symptoms for more than 2 months at a time.

Disruptive Mood Dysregulation Disorder (DMDD)

Severe recurrent temper outbursts that are grossly out of proportion to the situation plus persistently irritable/angry mood between outbursts. Outbursts occur on average 3+ times per week.

DMDD - Duration & Settings

Pattern lasts 12+ months, with no 3+ consecutive month symptom-free period. Symptoms occur in 2 or more settings and are severe in at least one.

DMDD - Age Rules

Diagnosis is made between ages 6-18. Onset of symptoms must be before age 10. Do not first diagnose before age 6 or after age 18.

DMDD vs Bipolar Disorder

DMDD involves chronic irritability, not distinct manic/hypomanic episodes. A history of a full manic or hypomanic episode points away from DMDD.

Premenstrual Dysphoric Disorder (PMDD)

Symptoms occur in the final week before menses, begin to improve within a few days after onset of menses, and become minimal/absent in the week after menses. At least 5 symptoms are required.

PMDD - Core Mood Symptoms

At least one: marked affective lability, marked irritability/anger or interpersonal conflict, markedly depressed mood/hopelessness/self-deprecating thoughts, or marked anxiety/tension/feeling keyed up.

PMDD - Confirmation

Symptoms should ideally be confirmed by prospective daily ratings during at least 2 symptomatic cycles. A provisional diagnosis may be made before prospective confirmation.

Substance/Medication-Induced Depressive Disorder

Prominent depressed mood or loss of interest develops during or soon after intoxication, withdrawal, or medication exposure, and the substance/medication is capable of producing the symptoms.

Depressive Disorder Due to Another Medical Condition

A prominent and persistent depressed mood or markedly diminished interest/pleasure is judged to be the direct pathophysiological consequence of another medical condition.

Other Specified Depressive Disorder

Clinically significant depressive symptoms cause distress/impairment but do not meet full criteria for a specific depressive disorder, and the clinician states the specific reason criteria are not met.

Unspecified Depressive Disorder

Clinically significant depressive symptoms cause distress/impairment but full criteria are not met, and the clinician does not specify the reason or lacks sufficient information for a more specific diagnosis.

MDD - Common Specifiers

Know common specifiers such as with anxious distress, mixed features, melancholic features, atypical features, mood-congruent or mood-incongruent psychotic features, catatonia, peripartum onset, and seasonal pattern.

Melancholic Features

Key pattern: loss of pleasure in almost all activities or lack of reactivity to usually pleasurable stimuli, plus features such as distinct depressed quality, morning worsening, early awakening, psychomotor change, significant anorexia/weight loss, or excessive guilt.

Atypical Features

Requires mood reactivity plus features such as significant weight/appetite increase, hypersomnia, leaden paralysis, or long-standing rejection sensitivity causing impairment.

With Anxious Distress

Depressive episode accompanied by symptoms such as feeling keyed up/tense, unusual restlessness, difficulty concentrating because of worry, fear something awful may happen, or fear of losing control.

With Mixed Features

A depressive episode accompanied by several manic/hypomanic-type symptoms, but not enough to meet full criteria for a manic/hypomanic episode.

With Psychotic Features

Depression may include delusions or hallucinations. Psychotic content can be mood-congruent (themes consistent with depression) or mood-incongruent.

With Peripartum Onset

Specifier may be used when onset of the mood episode occurs during pregnancy or within 4 weeks following delivery under DSM criteria.

With Seasonal Pattern

A regular temporal relationship exists between onset/remission of depressive episodes and a particular season, with the seasonal pattern predominating over nonseasonal episodes over the relevant period.

MDD vs PDD

MDD: more acute episode, minimum 2 weeks, 5+ symptoms. PDD: chronic depressed mood, 2+ years adults/1+ year youth, plus 2+ associated symptoms.

MDD vs Bipolar Depression

Before diagnosing unipolar MDD, assess for past mania or hypomania. A manic episode supports Bipolar I; a history of hypomania plus major depression may support Bipolar II rather than MDD.

Depression vs Normal Sadness

Clinical depression is distinguished by symptom number, duration, severity, functional impairment, associated cognitive/vegetative symptoms, and context - not sadness alone.

Depression - Risk Factors

Possible risk factors include prior depressive episodes, family history, trauma/adverse experiences, chronic stress, medical illness, substance use, social isolation, and major life stressors. Risk factors do not by themselves establish a diagnosis.

Depression - Protective Factors

Examples include social support, reasons for living, effective coping skills, treatment engagement, stable housing/resources, access to care, problem-solving ability, and restricted access to lethal means when suicide risk is present.

Assessment Priority

Assess symptoms, duration, impairment, medical/substance contributors, medications, history of mania/hypomania, psychosis, trauma/stressors, and suicide/self-harm risk. Rule-outs are crucial.

NCE/ASWB Exam Tip - FIRST/NEXT

When a vignette includes immediate safety concerns, assess/protect safety first. Otherwise, gather enough information and assess before jumping to intervention, diagnosis, referral, or confrontation.

NCE/ASWB Exam Tip - Medication

Counselors/social workers generally do not prescribe. Monitor symptoms/side effects within scope, encourage adherence as appropriate, coordinate with the prescriber with proper consent, and refer medication questions to the qualified prescriber.

NCE/ASWB Exam Tip - Differential Diagnosis

Look for the clue that changes the diagnosis: 2 weeks vs 2 years, chronic irritability vs episodic mania, menstrual-cycle timing, substance/medication timing, or a direct medical cause.

Scenario: 3 weeks of anhedonia + 5 depressive symptoms

If symptoms cause impairment and exclusions are satisfied, the best fit is generally Major Depressive Disorder. Always check for prior mania/hypomania before settling on unipolar depression.

Scenario: Depressed most days for 3 years

If chronic depressed mood plus at least 2 PDD-associated symptoms are present and symptom-free periods do not exceed 2 months, think Persistent Depressive Disorder.

Scenario: 9-year-old with chronic irritability + explosive outbursts

If outbursts occur 3+ times/week for 12+ months, are present in multiple settings, onset was before age 10, and there is no manic/hypomanic episode, think DMDD.

Scenario: Depression appears only around menstrual cycle

If symptoms reliably emerge in the late luteal phase, improve shortly after menses begins, are minimal after menses, and meet the symptom threshold, consider PMDD.

Scenario: Depressive symptoms begin after a new medication

Consider Substance/Medication-Induced Depressive Disorder if timing and known effects support causation. Also consider whether an independent depressive disorder better explains the presentation.

Scenario: Depression with past manic episode

Do not diagnose MDD if the depressive presentation is better accounted for by a bipolar disorder. A past manic episode is a major diagnostic clue toward Bipolar I Disorder.

High-Yield Number: MDD

5 symptoms / 2 weeks; one symptom must be depressed mood or anhedonia.

High-Yield Number: PDD

2 years adults / 1 year youth; depressed/irritable mood plus at least 2 associated symptoms.

High-Yield Number: DMDD

3+ outbursts/week, 12+ months, 2+ settings, diagnosis age 6-18, onset before 10.

High-Yield Number: PMDD

5+ symptoms tied to the menstrual cycle, including at least one core mood symptom.

Memory Trick - MDD

SIGECAPS + depressed mood. Remember that anhedonia or depressed mood must be one of the qualifying symptoms.

Memory Trick - PDD

Think: persistent = prolonged. The key discriminator is chronicity: 2 years in adults, 1 year in youth.

Memory Trick - DMDD

Think: child + chronic angry mood + repeated severe outbursts, rather than distinct manic episodes.

Memory Trick - PMDD

Think: predictable premenstrual pattern with improvement after menses begins.